<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200765
Report Date: 09/21/2021
Date Signed: 09/21/2021 04:02:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PLEASANT HILL OASISFACILITY NUMBER:
079200765
ADMINISTRATOR:ELEGADO, LIZAFACILITY TYPE:
740
ADDRESS:40 BOYD RDTELEPHONE:
(925) 937-5348
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:44CENSUS: 42DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Liza Elegado, AdministratorTIME COMPLETED:
04:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/21/21 at 3PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. Facility is a single story building with 24 bedrooms with in room toilets, 2 private rooms with shower & toilet and 5 common toilets and showers. LPA observed 11 staff wearing face masks during visit with 5 residents watching TV in the activities room while the other 37 residents were observed relaxing inside their bedrooms. Facility has a completed mitigation plan in place dated 12/31/2020 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. LPA observed screening station located near the front entrance with visitor's log, COVD-19 questionnaire, hand sanitizer, gloves, face masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff, residents and visitors.

LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. Facility has a visitation area with furniture spaced six feet apart for social distancing among residents.

Continued on next page LIC 809-C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PLEASANT HILL OASIS
FACILITY NUMBER: 079200765
VISIT DATE: 09/21/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A written Emergency/Disaster plan dated 08/08/2021 was posted in a common hallway leading to the activities room. Centrally stored medications were locked in the medication room. Sharp objects were also locked in the medication room. Toxic chemicals were locked in the laundry/chemical rooms. Adequate supply of PPE was observed stored in the hallway closet. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. Trash bins with lid operated foot pedal were located inside bedrooms, bathrooms and kitchen.

Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since March 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the kitchen and outside storage shed. Facility room temperature was maintained at 74 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 09/22/2021:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2